MAUDE Adverse Event Report: PIONEER SURGICAL TECHNOLOGY NANOSS 3D ADVANCED BONE GRAFT SUBSTITUTE; BONE VOID FILLER

Model Number	90-300-251004
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	Urinary Retention (2119)
Date of Event	07/29/2022
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device remains in patient and is not available for investigation.A dhr review was performed and the device was manufactured to specifications.This report will be updated should this information become available at a later date.
Event or Problem Description
Our distribution partner surgalign reported the following "dos (b)(6) 2022 able to void & use commode.Pod#3 (b)(6) 2022 feels urge to void but not able to void.Bladder scan >1000ml residual; pt straight catheterized.4 hrs later same feeling of need to void but not able to void.#18fr foley catheter inserted.D/c hospital with foley in place.Voiding trial 1 week later (b)(6) 2022 failed.Repeat voiding trial (b)(6) 2022.Success.Foley catheter discontinued".

• Brand Name: NANOSS 3D ADVANCED BONE GRAFT SUBSTITUTE
• Common Device Name: BONE VOID FILLER
• Manufacturer (Section D): PIONEER SURGICAL TECHNOLOGY; 375 river park circle; marquette MI 49855
• Manufacturer (Section G): PIONEER SURGICAL TECHNOLOGY; 375 river park circle; marquette MI 49855
• Manufacturer Contact: casey sumlin ; 375 river park circle; marquette, MI 49855
• MDR Report Key: 15685557
• Report Number: 1833824-2022-00136
• Device Sequence Number: 6497614
• Product Code: MQV
• UDI-Device Identifier: 00846468049560
• UDI-Public: (01)00846468049560(17)230228(10)401932
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K132050
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 10/27/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 02/28/2023
• Device Model Number: 90-300-251004
• Device Catalogue Number: 90-300-251004
• Device Lot Number: 401932
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/28/2022
• Initial Report FDA Received Date: 10/27/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 01/19/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown